Brachial-ankle PWV for predicting clinical outcomes in patients with acute stroke

Advanced vascular aging and outcomes after acute ischemic stroke: a systematic review and meta-analysis

Pulse wave velocity (PWV) is as a reliable marker of arterial stiffness and vascular aging, surpassing traditional risk factors in predicting detrimental cardiovascular events. The present meta-analysis aims to investigate PWV thresholds and assess its prognostic value in outcomes of acute ischemic stroke (AIS). A search was conducted in PubMed, Cochrane, Web of Science, and Scopus for studies published up to January 2024, focusing on patients admitted with AIS, wherein arterial stiffness was assessed through PWV measurements during hospitalization. Identified studies reported PWV values in individuals with both favorable and unfavorable outcomes at the end of follow-up. Initially, 35 eligible studies provided data for weighted mean baPWV (11,953 AIS patients) and cfPWV (2,197 AIS patients) calculations. The average age was 67 years, with approximately 60% male, 67% hypertensive, 30% diabetic and 30% smoker participants. The weighted mean systolic blood pressure was approximately 150 mmHg. In AIS patients, the mean PWV was 10 m/s for standard cfPWV and 20 m/s for baPWV. Nine cohort studies (6,006 AIS patients) were included in the quantitative analysis of clinical outcomes. Higher PWV levels were associated with poorer functional outcomes (2.3 m/s higher, 95%CI:1.2-3.4, p < 0.001; I2 = 87.4%). AIS patients with arterial stiffness/vascular aging (higher PWV) had approximately 46.2% increased risk of poor functional outcome, 12.7% higher risk of mortality, 13.9% greater risk of major adverse cardiovascular events, and 13.9% greater risk of stroke recurrence over the long term compared to those without arterial stiffness. Advanced vascular aging, as indicated by PWV, significantly predicts adverse outcomes in AIS patients. Integrating the assessment of vascular aging into clinical practice can improve risk perception in these patients.

Prognostic value of arterial stiffness according to the cardiovascular risk profiles

It is not clear whether the influence of arterial stiffness depends on the subject's cardiovascular risk status. This study was performed to assess the prognostic value of arterial stiffness according to different cardiovascular risk profiles. A total of 11,767 subjects (61 years and 58% males) who underwent brachial-ankle pulse wave velocity (baPWV) measurement were retrospectively analyzed. Subjects were stratified into three groups: (1) those with traditional risk factor ≤1 and without atherosclerotic cardiovascular disease (ASCVD), (2) those with traditional risk factors ≥2 and without ASCVD, or (3) those with documented ASCVD. Composite events of cardiac death, non-fatal myocardial infarction, coronary revascularization and stroke were assessed during the clinical follow-up period. Compared to patients with risk factor ≤1, those with risk factor ≥2 and those with ASCVD were older, and more frequently had unfavorable laboratory findings, and higher baPWV values. During the median follow-up of 1329 days (interquartile range, 570-1,965 days), there were 350 composite events (3.0%). In multivariable Cox regression analyses, higher baPWV value was independently associated with higher incidence rate of composite events even after controlling for potential confounders in all three groups (P < 0.05 for each). In this study, it was found that baPWV was independently associated with the occurrence of cardiovascular events irrespective of baseline cardiovascular risk profiles, suggesting that baPWV is useful for risk stratification in mass screening.

Brachial-ankle pulse wave velocity and prognosis in patients with atherosclerotic cardiovascular disease: a systematic review and meta-analysis

Arterial stiffness has been suggested as an independent cardiovascular risk factor. This systematic review and meta-analysis aimed to quantify the association between brachial-ankle pulse wave velocity (baPWV) and prognosis in atherosclerotic cardiovascular disease (ASCVD) patients. The PubMed, EMBASE, and Cochrane Library databases were searched for cohort studies examining the association of high baPWV with prognosis in ASCVD patients. High baPWV was defined by the cutoffs provided by each study. The outcomes of interest were cardiovascular events, cardiovascular mortality, and all-cause mortality. Hazard ratios (HRs) and 95% confidence intervals (CIs) were combined using the random-effects model with inverse variance weighting. We identified 15 studies that were eligible for inclusion in the meta-analysis. The overall HRs and 95% CIs of cardiovascular events, cardiovascular mortality, and all-cause mortality for high baPWV were 2.55 (1.61-4.03), 2.66 (1.88-3.76), and 1.77 (1.09-2.87), respectively. The association between baPWV and cardiovascular events remained significant, irrespective of determination methods for cutoffs of baPWV, classification of ASCVD, outcome definitions, Newcastle-Ottawa Scale score and average age, independent of age and hypertension. Significantly higher HRs were observed in the subgroups of >3 years follow-up duration (p for interaction: 0.04), cutoff points by ROC curves (p for interaction: 0.04) and an average age of <65 years (p for interaction: 0.01). A 1 standard deviation increase in baPWV was associated with a 1.41-fold (1.24-1.60) increase in the risk of cardiovascular events. High baPWV is independently associated with an increased risk of cardiovascular events, cardiovascular mortality, and all-cause mortality in ASCVD patients.

Improved Prognostic Value in Predicting Long-Term Cardiovascular Events by a Combination of High-Sensitivity C-Reactive Protein and Brachial-Ankle Pulse Wave Velocity

Background: Both C-reactive protein (CRP) and arterial stiffness are associated with the development of cardiovascular disease (CVD). This study was performed to investigate whether a combination of these two measurements could improve cardiovascular risk stratification. Methods: A total of 6572 consecutive subjects (mean age, 60.8 ± 11.8 years; female, 44.2%) who underwent both high-sensitivity CRP (hs-CRP) and brachial–ankle pulse wave velocity (baPWV) measurement within 1 week were retrospectively analyzed. Major adverse cardiovascular events (MACE), including cardiovascular death, acute myocardial infarction, coronary revascularization, and stroke were assessed during the clinical follow-up. Results: During a mean follow-up period of 3.75 years (interquartile range, 1.78–5.31 years), there were 182 cases of MACE (2.8%). The elevated baPWV (≥1505 cm/s) (hazard ratio (HR), 4.21; 95% confidence interval (CI), 2.73–6.48; p < 0.001) and hs-CRP (≥3 mg/L) (HR, 1.57; 95% CI, 1.12–2.21; p < 0.001) levels were associated with MACE even after controlling for potential confounders. The combination of baPWV and hs-CRP further stratified the subjects’ risk (subjects with low baPWV and hs-CRP vs. subjects with high baPWV and hs-CRP; HR, 7.08; 95% CI, 3.76−13.30; p < 0.001). Adding baPWV information to clinical factors and hs-CRP had an incremental prognostic value (global Chi-square score, from 126 to 167, p < 0.001). Conclusions: The combination of hs-CRP and baPWV provided a better prediction of future CVD than either one by itself. Taking these two simple measurements simultaneously is clinically useful in cardiovascular risk stratification.

Blood Pressure Management in Acute Ischemic Stroke

PURPOSE OF REVIEW

Abrupt blood pressure (BP) rise is the most common clinical symptom of acute ischemic stroke (AIS). However, BP alterations during AIS reflect many diverse mechanisms, both stroke-related and nonspecific epiphenomena, which change over time and across patients. While extremes of BP as well as high BP variability have been related with worse outcomes in observational studies, optimal BP management after AIS remains challenging.

RECENT FINDINGS

This review discusses the complexity of the factors linking BP changes to the clinical outcomes of patients with AIS, depending on the treatment strategy and local vessel status and, in particular, the degree of reperfusion achieved. The evidence for possible additional clinical markers, including the presence of arterial hypertension, and comorbid organ dysfunction in individuals with AIS, as informative and helpful factors in therapeutic decision-making concerning BP will be reviewed, as well as recent data on neurovascular monitoring targeting person-specific local cerebral perfusion and metabolic demand, instead of the global traditional parameters (BP among others) alone. The individualization of BP management protocols based on a complex evaluation of the homeostatic response to focal cerebral ischemia, including but not limited to BP changes, may be a valuable novel goal proposed in AIS, but further trials are warranted.

State of the Art Review: Brachial-Ankle PWV

The brachial-ankle pulse wave velocity (brachial-ankle PWV), which is measured simply by wrapping pressure cuffs around the four extremities, is a simple marker to assess the stiffness of the medium- to large- sized arteries. The accuracy and reproducibility of its measurement have been confirmed to be acceptable. Risk factors for cardiovascular disease, especially advanced age and high blood pressure, are reported to be associated with an increase of the arterial stiffness. Furthermore, arterial stiffness might be involved in a vicious cycle with the development/progression of hypertension, diabetes mellitus and chronic kidney disease. Increase in the arterial stiffness is thought to contribute to the development of cardiovascular disease via pathophysiological abnormalities induced in the heart, brain, kidney, and also the arteries themselves. A recent independent participant data meta-analysis conducted in Japan demonstrated that the brachial-ankle PWV is a useful marker to predict future cardiovascular events in Japanese subjects without a previous history of cardiovascular disease, independent of the conventional model for the risk assessment. The cutoff point may be 16.0 m/s in individuals with a low risk of cardiovascular disease (CVD), and 18.0 m/s in individuals with a high risk of CVD and subjects with hypertension. In addition, the method of measurement of the brachial-ankle PWV can also be used to calculate the inter-arm systolic blood pressure difference and ankle-brachial pressure index, which are also useful markers for cardiovascular risk assessment.

Static intra-access pressure ratio and cardiovascular events in patients undergoing haemodialysis

Static intra-access pressure ratio (SIAPR) measurement, using haemodialysis machine transducers, is the vascular access surveillance method in patients undergoing haemodialysis. However, little is known about the relationship between the SIAPR and arterial stiffness, and the clinical usefulness of the SIAPR in predicting cardiovascular events. A total of 209 patients undergoing maintenance haemodialysis were evaluated. The SIAPRs ranged from 0.01 to 0.52 (median: 0.23). When the patients were divided into two groups according to their median of SIAPR, the incidence of previous cardiovascular disease, E/E' ratio, and brachial-ankle pulse wave velocity were significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23. Conversely, patients with worse comorbid status had a lower SIAPR than patients without it. In the Kaplan-Meier analysis, the cumulative incidence of cardiovascular events was significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23 (P < 0.001). In the multiple Cox regression analysis, an increase in the SIAPR was associated with a reduced risk for cardiovascular events [hazard ratio: 0.36, 95% confidence interval: 0.21-0.60, P = 0.001]. Therefore, a low SIAPR related with arterial stiffness was a predictor for cardiovascular events.

Brachial-ankle pulse wave velocity, cardio-ankle vascular index, and prognosis

Background

Brachial–ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are indices of arterial stiffness, and several studies have used these indices. However, there is no comprehensive review of these parameters in the prognostic significance.

Methods

The aim of this study was to review the articles exploring the prognostic significance of these parameters. Articles demonstrating independent significance after multivariate analysis on the Cox proportional hazards model were defined as “successful.” The success rate was compared using Fisher’s exact test. In addition, multivariate logistic regression analysis was performed to explore the independent determinants of the success of prognostic prediction.

Results

The success rate of the baPWV articles (65.7% [46/70]) tended to be higher than that of the CAVI articles (40.0% [6/15]; P=0.083). Multivariate analysis demonstrated that log (number of patients) (OR 11.20, 95% CI 2.45–51.70, P=0.002) and dialysis population (OR 0.28, 95% CI 0.08–0.94, P=0.039) were positive and negative independent determinants of the success of prognostic prediction, respectively. In addition, after redefining two studies as the absence of arteriosclerosis obliterans (ASO) exclusion, baPWV (OR 3.36, 95% CI 0.86–13.20, P=0.083) and the existence of exclusion criteria of ASO (OR 3.08, 95% CI 0.96–9.93, P=0.060) exhibited statistical tendency in the multivariate analysis.

Conclusion

This study demonstrated that the number of study participants and dialysis population were the independent determinants of the success of prognostic prediction. This study also showed the importance of exclusion criteria of ASO when using these indices. In addition, a prospective large-scale study to confirm the superiority in the prognostic prediction of these indices is warranted.